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Of the upcoming new approaches, what do you expect to be the best for the treatment of early presbyopia?
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Drops will likely be the easier, least invasive option
There is a lot of excitement around the new eye drops for presbyopia, which should hopefully become available in the U.S. in the next 1 to 2 years. The beauty of this pharmacological option is that patients can try the drops and determine how effective they are and how well they tolerate them before committing to long-term use. It is the least invasive and easiest way to reverse the symptoms of presbyopia and reduce the need for reading glasses, with no known long-term downside or risk. Once available, patients will have the option to trial these medications. If not satisfied with the level of improvement in reading vision, or if the side effects are not well tolerated, patients can, of course, elect surgical options to improve their reading vision.
These medications are currently considered investigational, as they are in the midst of clinical trials with the goal of FDA approval in the near future. Allergan, Novartis, Presbyopia Therapies and Orasis are four companies with planned or ongoing clinical trials. Each company has a presbyopia eye drop with different components. Once the clinical trials have been completed, more data will be available on how each of the medications will work for individual patients. Because there will likely be differences, individual patients will have the opportunity to see what works best for them.
The drops are at different stages of clinical trials. Early studies have so far been positive. They seem to be well tolerated, providing improvement for presbyopic patients with low refractive errors. Depending on the patient’s refractive error, they have the potential to provide enough range of vision to be able to read small print and work at the computer without spectacle aid. Personally, as a minimally myopic presbyope, I am looking forward to having these medications available. I wear reading glasses for very small print but would like to reduce my dependence even further.
Once these medications become available, I believe that for many patients these will be an excellent first-line option for early presbyopic patients, assuming that side effects are mild and/or transient. Of course, there is always the potential that these medications can exacerbate dry eye or have another side effect, so not all patients will be perfect candidates. Patients who do not respond well or do not tolerate the side effects can just discontinue the treatment without consequences.
In summary, the future is exciting for our presbyopic patients, and once presbyopia drops become available, we likely will see an increased number of patients who will seek our help. Because drops will likely help many patients but not all patients, it will also be important for clinicians to have a solid understanding of surgical options, which also have a bright future as our population ages.
William B. Trattler, MD, is OSN Technology Section Editor. Disclosure: Trattler reports he is a consultant to Allergan and Novartis and has a financial interest in Visionary Ventures, which has a financial interest in Orasis.
Scleral microporation is effective, not invasive
I have worked for about 2 years now on laser scleral microporation (Ace Vision Group), a new technique that is effective and not invasive. This is what I would use for young presbyopes, 45 to 50 years of age, a group of patients in which I would be reluctant to perform clear lens exchange. We have now become aware that presbyopia is not only related to stiffening of the lens, but also to loss of elasticity and pliability of the ciliary muscles and sclera. Laser scleral microporation rejuvenates the scleral tissue and restores true accommodation. I performed my first operations in Cambodia with a first-generation prototype, and I could tell that patients were able to read small prints from the first day after surgery, and within a month, in many cases already after 1 week, the spots on the sclera were no longer visible. There is now a new second-generation prototype tested with even better features, and we are developing a new option of re-treating patients after a few years when presbyopia progresses. The new OCT-guided technology will allow us to direct the laser beam exactly to the same spots that we treated originally.
Personally, this is the scleral procedure I would choose. I was also involved in the Refocus study on the VisAbility microstent procedure and operated on some patients in Belize. The procedure works well and gives stable results, but it is longer and more invasive. It has also a recovery time of about 2 weeks, which may not suit active patients in our Western societies who want quick recovery to go back to work as soon as possible.
As far as drops are concerned, I am not too sure about that option. They may be good for a short time, but in the long run, patients get annoyed with putting drops every day in the eye and do not like the side effects. Many people presbyopic age have dry eye issues, and allergies are also common, and I think that many patients will get tired after a while of the discomfort that drops may cause.
Magda Rau, MD, is from Augenklinik Cham, Cham, Germany. Disclosure: Rau reports no relevant financial disclosures.